<%@ page language="java" contentType="text/html; charset=ISO-8859-1"
	pageEncoding="ISO-8859-1"%>
<%@ taglib prefix="form" uri="http://www.springframework.org/tags/form"%>
<%@ taglib uri="http://java.sun.com/jsp/jstl/core" prefix="c"%>  
<%@ taglib prefix="sec" uri="http://www.springframework.org/security/tags" %>
<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=ISO-8859-1">
<link rel="stylesheet" href="resources/mytheme/css/main.css">
<title>Claim Review/Confirmation</title>

<link rel="stylesheet" href="resources/mytheme/css/jquery-ui.css" type="text/css" media="screen" />
<script type="text/javascript" src="resources/js/jquery-1.8.3.js"></script>
<script type="text/javascript" src="resources/js/jquery-ui.js"></script>
<link rel="stylesheet" href="resources/mytheme/css/jquery.ui.chatbox.css">
<script type="text/javascript" src="resources/js/jquery.ui.chatbox.js"></script>
<script src="http://ajax.googleapis.com/ajax/libs/jquery/1.11.1/jquery.min.js"></script>

<script type="text/javascript">

		$(document).ready(function()
		{
			var box = null;
			
			$("#chatLink").click(function(event, ui)
			{
				if(box)
				{
					box.chatbox("option", "boxManager").toggleBox();
				}
				else
				{
					box = $("#chat_div").chatbox(
					{
						id:"Runnable",
                        user:
						{
							key : "value"
						},

						title : "Acme Claims Health Chat",
						messageSent : function(id, user, msg)
						{
							$("#log").append(id + " said: " + msg + "<br/>");
                            $("#chat_div").chatbox("option", "boxManager").addMsg(id, msg);
                        }
					});
				}
			});
		});
    </script>
</head>
<body>
	<div id="headerContainer">
		<div class="centerContainer">
		<p id="demo" style="visibility: hidden;" />
		<div id="chat_div" ></div>
			<ol>
			<sec:authorize ifAllGranted="ROLE_ADMIN">
				<li><a href="AdminUsers">Users</a></li>
				<li><a href="AdminRejectedClaims">Rejected Claims</a></li>
				<li><a href="AdminAcceptedClaims">Accepted Claims</a></li>
				<li><a href="AdminAllClaims">All Claims</a></li>
			</sec:authorize>
			<sec:authorize ifAnyGranted="ROLE_ADMIN, ROLE_ADJUSTER">
				<li><a href="InsuranceAdjuster">Adjust Claims</a></li>
			</sec:authorize>
			</ol>
		</div>
		<!-- /centerContainer -->

	</div>
	<!-- /headerContainer -->

	<div id="secondHeaderContainer">
		<div class="logoContainer">
			<img src="resources/mytheme/images/logo2.png" alt="logo" width="205"
				height="89">
		</div>
		<!-- /logoContainer -->
		<div class="navContainer">

			<ul id="navWrapper">
				<li><a href="/AcmeClaims">Home</a></li>
				<sec:authorize ifNotGranted="ROLE_ADMIN">
				<c:if test="${pageContext.request.userPrincipal.name != null}">
					<li>
						<!-- Menu A --> <a href="#">Claims</a>
						<ul>
							<li><a href="ClaimPortal">Submit Claim</a></li>
							<li><a href="MyAccount">View Claim</a></li>
						</ul>
					</li>
					<li><a href="MyAccount">My Account</a></li>
				</c:if>
				</sec:authorize>
				<li><a href="locatedoctor">Find a Doctor</a></li>
			</ul>
		</div>
		<!-- /navContainer -->
	</div>
	<!-- /secondHeaderContainer -->

	<div id="thirdHeaderContainer">
		<div class="lowerheaderContainer">
			<c:if test="${pageContext.request.userPrincipal.name != null}">
				<ol>
					<li><a href="<c:url value="/MyAccount" />">${pageContext.request.userPrincipal.name}</a></li>
					<li>|</li> 
	                <li><a href="<c:url value="/Logout" />" > Logout</a></li>
                 </ol> 
			</c:if>
			<c:if test="${pageContext.request.userPrincipal.name == null}">
				<ol>
					<li><a href="Login">Log-In</a></li>
					<li>|</li>
					<li><a href="register">Register</a></li>
				</ol>
			</c:if>
		</div>
		<!-- /lowerHeader-->
	</div>
	<!--/thirdHeaderContainer"-->
	<form:form commandName="claim">
		<!-- <div id="claimTable"> -->
			<div class="mainCenterContainerClaimReg">
				<div class="claimNav"></div>
				<div class="claimTable">
					<h1>Claim Review/Confirmation</h1>
					<table>
						<tr>
							<td>
								<label>First Name:</label>
							</td>
							<td>
								<form:input id="firstName" path="user.fName" />
							</td>
							<td>
								<font color='red'><form:errors path="user.fName" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>Last Name:</label>
							</td>
							<td>
								<form:input id="lastName" path="user.lName" />
							</td>
							<td>
								<font color='red'><form:errors path="user.lName" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>Gender</label>
							</td>
							<td>
								<form:radiobutton path="user.gender" value="Male" /> M 
								<form:radiobutton path="user.gender" value="Female" /> F
							</td>
							<td>
								<font color='red'><form:errors path="user.gender" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>Identification Number</label>
							</td>
							<td>
								<form:input name="idNum" path="user.insuranceNumber" />
							</td>
							<td>
								<font color='red'><form:errors path="user.insuranceNumber" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>Date of Birth</label>
							</td>
							<td>
								<form:input type="date" path="user.birthday"/>
							</td>
							<td>
								<font color='red'><form:errors path="user.birthday" /></font>
							</td>
						</tr>
						<tr>
							<td colspan="2" style="text-align: left">
								<h2>Injury Information</h2>
							</td>
						</tr>
						<tr>
							<td>
								<label>A) Accident or Illness due to employment?</label>
							</td>
							<td>
								<form:radiobutton name="aoi" value="true" path="jobRelated" /> Yes 
								<form:radiobutton name="aoi" value="false" path="jobRelated" /> No
							</td>
							<td>
								<font color='red'><form:errors path="jobRelated" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>B) Is this service related to:</label>
							</td>
							<td>
								<form:radiobutton name="iAuto" value="Illness" path="type" /> Illness
								<form:radiobutton name="iAuto" value="Injury" path="type" /> Injury 
								<form:radiobutton name="iAuto" value="Maternity" path="type" /> Maternity
								<form:radiobutton name="iAuto" value="Auto Accident" path="type" /> Auto Accident
							</td>
							<td>
								<font color='red'><form:errors path="type" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>D) Date of Accident or Beginning of Illness</label>
							</td>
							<td>
								<form:input type="date" name="doi" path="date" />
							</td> 
							<td>
								<font color='red'><form:errors path="date" /></font>
							</td>
						</tr> 
						<tr>
							<td>
								<label>C) Symptom/Diagnosis</label>
							</td>
							<td>
								<form:textarea rows="10" name="symptom" id="styled" cols="40" path="diagnosis" ></form:textarea>
							</td>
							<td>
								<font color='red'><form:errors path="diagnosis" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>E) Were you hospitalize</label>
							</td>
							<td>
								<form:radiobutton name="isHosp" value="true" path="hospitalized" /> Yes
								<form:radiobutton name="isHosp" value="false" path="hospitalized" /> No
							</td>
							<td>
								<font color='red'><form:errors path="hospitalized" /></font>
							</td>
						</tr>
						<tr>
							<td colspan="2" style="text-align: left">
								<h2>Hospital Information</h2>
							</td>
						</tr>
						<tr>
							<td>
								<label>Hospital Name</label>
							</td>
							<td>
								<form:input name="hospName" path="hospitalName" />
							</td>
							<td>
								<font color='red'><form:errors path="hospitalName" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>Admission Date</label>
							</td>
							<td>
								<form:input type="date" name="adDate" path="hospAdmitDate" />
							</td>
							<td>
								<font color='red'><form:errors path="hospAdmitDate" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>Discharge Date</label>
							</td>
							<td>
								<form:input type="date" name="disDate" path="hospDischargeDate" />
							</td>
							<td>
								<font color='red'><form:errors path="hospDischargeDate" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>Name of Physician</label>
							</td>
							<td>
								<form:input name="physName" path="admittingPhysician" />
							</td> 
							<td>
								<font color='red'><form:errors path="admittingPhysician" /></font>
							</td>
						</tr>
						<tr>
							<td colspan="2" style="text-align: left">
								<h2>Insurance Information</h2>
							</td>
						</tr>
						<tr>
							<td>
								<label>Do you have Medicare coverage?</label>
							</td>
							<td>
								<form:radiobutton name="coverageType" value="true" path="medicare" /> Yes
								<form:radiobutton name="coverageType" value="false" path="medicare" /> No
							</td>
							<td>
								<font color='red'><form:errors path="medicare" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>Medicare Number</label>
							</td>
							<td>
								<form:input name="medNum" path="medicareNumber" />
							</td>
							<td>
								<font color='red'><form:errors path="medicareNumber" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>Eligible for Medicare Part A?</label>
							</td>
							<td>
								<form:radiobutton name="medA" value="true" path="medicareA" /> Yes
								<form:radiobutton name="medA" value="false" path="medicareA" /> No
							</td>
							<td>
								<font color='red'><form:errors path="medicareA" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>Eligible for Medicare Part B?</label>
							</td>
							<td>
								<form:radiobutton name="medB" value="true" path="medicareB" /> Yes
								<form:radiobutton name="medB" value="false" path="medicareB" /> No
							</td>
							<td>
								<font color='red'><form:errors path="medicareB" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>Do you have other insurance coverage?</label>
							</td>
							<td>
								<form:radiobutton name="otherIns" value="true" path="otherInsurance" /> Yes
								<form:radiobutton name="otherIns" value="false" path="otherInsurance" /> No
							</td>
							<td>
								<font color='red'><form:errors path="otherInsurance" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>Name of Insurance Company</label>
							</td>
							<td>
								<form:input name="otherInsName" path="otherInsCompName" />
							</td>
							<td>
								<font color='red'><form:errors path="otherInsCompName" /></font>
							</td>
						</tr>
						<tr>
							<td>
								<label>Identification Number</label>
							</td>
							<td>
								<form:input name="otherInsID" path="otherInsCompID" />
							</td>
						</tr>
					</table>
					<br>
					<div class="nextLink">
						<input type="submit" value="Back" name="_target4"/>
						<input type="submit" value="Submit" name="_nextFinal"/>
					</div>					
				</div>
			</div>
		<!-- </div> -->
	</form:form>	
	<div id="footer">
		<div class="footerwrap">
			<div class="foota">
			<br>
			<p>Connect With Us</p>
				<div id="footapad"><a href="#"><img src="resources/mytheme/images/fb.png" id="facebook" alt="logo" width="67" height="73"/></a>
				<a href="#"><img src="resources/mytheme/images/twit.png" id="twitter" alt="logo" width="65" height="73"/></a>
				<a href="#"><img src="resources/mytheme/images/pin.png" id="pintrest" alt="logo" width="67" height="73"/></a>
				
				
				</div>
			</div>
			<div class="footb">
			<br>
				<p>Toll Free: 1-800-382-3827</p>
				  <ol>
					<li>Acme Corporate</li>
					<li>143 23rd Ave South</li>
					<li>Fargo, North Dakota 58121</li>
				</ol>
			</div>
			<div class="footc">
			<br>
				<p>Need Help?</p>
				  <ol>
				    <li><a href="#" id="chatLink">Join Live Chat</a></li>
					<li><a href="ContactUs">Contact Us</a></li>
					<li><a href="FAQ">FAQ's</a></li>
				</ol>
				 
			</div>
		</div><!-- FooterWrap -->
	</div><!-- Footer -->
</body>
</html>